Inconsistent Documentation of Controlled Substance Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident when documentation in the Medication Administration Record (MAR) and the Controlled Substance Register regarding the administration of Oxycodone conflicted. Specifically, the MAR indicated that the resident received Oxycodone IR 10 mg at 2:26 A.M., while the Controlled Substance Register documented administration at 4:00 A.M. on the same day. Additionally, there was no documentation in the medical record to support that a nurse administered a PRN dose of Oxycodone IR 5 mg at 12:35 A.M. on a different date, despite this being recorded elsewhere. These discrepancies made it unclear which record was accurate and resulted in confusion regarding when the resident was eligible for their next dose. The resident involved had multiple complex diagnoses, including hepatic encephalopathy, severe sepsis, alcoholic cirrhosis, type 2 diabetes, anemia in chronic kidney disease, opioid dependence, chronic pain syndrome, neuropathy, gout, sleep apnea, lumbar radiculopathy, and hypertension. Interviews with facility staff confirmed that nurses did not consistently document all administered medications in the medical record, and that the times recorded in the MAR and Controlled Substance Register did not always match. This lack of accurate and consistent documentation was contrary to facility policy and led to errors in determining appropriate medication administration times.